HPI/ROS:

The patient is a 11 y.o. male with no past medical history who presents as trauma activation after MVC. Patient was the restrained front seat passenger in a head on collision. Denies LOC. Per EMS, patient was found in police cruiser on arrival, patient states he walked at scene. +Seatbelt sign. Vitals stable. Patient states his pain is worst in his neck, rates pain 6/10. Denies numbness/tingling.

 Vital Signs:  

BP 116/47  | Pulse (!) 115  | Resp 19  | Wt 37.5 kg  | SpO2 100%

Pertinent physical exam:

AIRWAY: intact  

BREATHING: non-labored Breath sounds: Clear to auscultation bilaterally

CIRCULATION: pulse palpable: Bilateral Radial, DP and PT pulses are normal and symmetric

Capillary refill: normal; less than 2 seconds

Head: normocephalic / atraumatic no hematoma, no abrasions

ENT: tympanic membranes bilaterally clear

Neck: trachea appears midline, there is a cervical collar in place. Abrasion/seatbelt sign over R neck. +midline c-spine ttp without stepoffs

Respiratory: clear to auscultation bilaterally

Cardiovascular: regular rate and rhythm. Seat belt sign across L anterior chest

Rectal: normal tone

Abdomen: soft, non-distended, normal bowel sounds, nonperitoneal with tenderness to palpation in RLQ. Seatbelt sign across lower abdomen and L anterior thigh

Back: no tenderness to palpation in t-spine or l-spine. No step offs. No abrasions or bruises.

Pelvis: non-tender, stable to anterior-posterior/lateral compression

Genitourinary: normal genitalia

Musculoskeletal: no palpable long bone deformities, no bony tenderness to palpation

Skin: grossly intact

Neurologic: GCS: eyes 4, best verbal response 5, best motor response 6 TOTAL GCS SCORE: 15. Bilateral upper extremity strength 5/5 at deltoids, biceps, triceps, and handgrip. Bilateral lower strength at 5/5 at hip flexion, dorsi-/plantarflexion.

Should this patient receive a CTA of the neck?

 

Review of the literature 

Blunt cervical vascular injury

Blunt cervical vascular injury (BCVI) has an incidence of 0.03-0.9% in pediatric blunt trauma. BCVI may cause ischemia and other neurologic sequelae. Most BCVI are treated medically with aspirin or anticoagulation. Higher grade lesions may require intervention including endovascular stenting or ligation. The development of focal neurologic findings may be delayed up to 10-72 hours, complicating diagnosis in the acute setting.[1]

Currently, the Eastern Association for the Surgery of Trauma (EAST) recommends that pediatric patients should be screened by adult criteria, called the Denver or Memphis criteria. The Denver criteria include “focal neurologic deficit, arterial hemorrhage, cervical bruit/thrill (<50 yo), infarct on head CT, expanding neck hematoma, neuro exam inconsistent with head CT, midface fractures, c-spine injuries, basilar skull fractures, GCS <8, hanging with anoxic brain injury, seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status. Isolated seatbelt sign without other neurologic symptoms has not been identified as a risk factor.”[2]

Evaluation with computed tomography angiogram (CTA) of the brain and neck represents a dose of radiation 8 times higher (16.4 millisieverts) than compared to a noncontrast CT of the brain and neck (2 millisieverts).[1] Exposure to ionizing radiation in the pediatric population has been shown to increase risks of cancers, especially leukemia, breast, and thyroid cancer.[3]

A recent, large study identifying risk factors associated with blunt cervical vascular injury (BCVI) examined 11,446 pediatric blunt trauma patients, with 375 (3.3%) undergoing CTA imaging. Fifty-three patients (0.4%) had cerebrovascular injuries, representing 0.5% of all pediatric blunt trauma patients and 14% of all blunt trauma patients screened with CTA.[1]

They found a seatbelt sign on the neck did not predict vascular injury.[1] These findings are consistent with other studies which did not find an association between  a cervical seatbelt sign and BCVI.[2,4] Furthermore, they identified independent predictors of cervical vascular injury: presence of cerebral hemorrhage, infarct on head imaging, cervical spine fracture, and basilar skull fracture.[1] Other studies have found associations between BCVI and clavicular fractures,[5] fracture through the carotid canal,[6] petrous temporal bone fracture,[6] GCS < 8,[6] focal neurological deficit,[6] and stroke on initial CT.[6]

  

Case Resolution

Due to the patient’s c-spine tenderness, in addition to the presence of a seat belt sign, the patient underwent imaging with a CT c-spine and a CTA brain and neck. He also had a CT of his abdomen.

All of his imaging (CTA brain/neck, CT c-spine, and CT abdomen and pelvis were all negative. The patient was admitted to the surgical service for pain management and serial exams of his abdomen. His repeat exam was normal and patient was discharged the following day.

Based on the above guidelines, a CTA of the brain and neck was not indicated.

Children of a certain size and age should not be sitting in the front seat and need booster seats. Here’s more information on that: http://brownemblog.com/blog-1/2019/1/10/hey-kiddo-take-a-seat

 

Faculty Reviewer: Dr. Jane Preotle

References

1. Irma T. Ugalde IT,  MD, Claibrne MK, Cardenas-Turanzas M, Shah MN, Langabeer JR, Patel R. Risk Factors in Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign. West J Emerg Med. 2018 Nov; 19(6): 961–969.

2. Denver screening criteria. WikEM

3. Risk of Ionizing Radiation Exposure to Children: A Subject Review. Committee on Environmental Health, American Association of Pediatrics. Pediatrics. 1998; 101(4).

4. Desai NK, Kang J, Chokshi FS. Screening CT Angiography for Pediatric Blunt Cerebrovascular Injury with Emphasis on the Cervical “Seatbelt Sign” American Journal of Neuroradiology September 2014, 35 (9) 1836-1840.

5. Lew SM, Frumiento C, Wald SL Pediatric blunt carotid inury: a review of the National Pediatric Trauma Registry. Pediatr Neurosurg, 1999; 30(5): 239-44. 

6. Ravindra VM, Bollo RJ, Sivakumar W, Akbari H, Naftel RP, Limbrick DD, JEa A, Gannon S, Shannon C, Birkas Y, Yang GL, Prather CT, Kestle JR, Riva-Cambrin J. Predicting Blunt Cerebrovascular Injury in Pediatric Trauma: Validation fo the “Utah Score.” J Neurotrauma. 2017; 34(2): 391-399.